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Process for assessment to determine if patient is high risk for readmission and discharge flow Patient admitted High Risk Screening Criteria for Potential Readmission Patients who fall into any of these categories should be reviewed to have a targeted comprehensive assessment completed Over the age of 70 Multiple diagnosis and co-morbidities Greater than 5 complex medications Impaired Mobility Impaired self care skills Poor cognitive status Catastrophic injury or illness Homelessness Poor social supports Chronic illness Anticipated long term health care needs (e.g.,new diabetic) Substance abuse History of multiple hospital admissions History of multiple emergent care use Initial nursing admission assessment/MD H&P reviewed for potential readmission using high risk screening criteria Hospital needs to identify accountable staff screen patients Is the patient at risk for readmission? Hospital needs to identify accountable staff to complete comprehensive assessment on identified patients yes no Is patient being discharged to TCU/ LTC, etc. ? Follow hospital’s normal discharge process yes Complete all required forms and Verbal handoff no no yes Discharge patient Will patient be receiving HC services ? no Contact PCP clinic for handoff communictaion Transfer patient Comprehensive assessment Patients who are identified as High Risk or those for whom a more comprehensive assessment is indicated should be evaluated using the following criteria The screening process is dynamic and may include other information not listed below. Functional assessment (the patients ability to perform ADL's and IADL's) Cognitive assessment if indicated Who are the patient's informal supports? What are the abilities of the informal supports? What is the availability of the informal supports? What is the patient's living arrangement? (home, apartment, with family, congregate living, homeless) This should include a description of the setting, such as stairs to enter, wheelchair accessibility, functional plumbing, heat, cooking facilities What is the patient's understanding of their illness? Is the patient capable of participating in his or her own discharge planning, if not, do they have someone who can represent them in the process? What are the patient's goals for discharge? What does the patient need to achieve functionally to achieve these goals? What services might be available to the patient to achieve these goals? What services did the patient have prior to admission?